How Would You Know You’re Not As Good As You Think You Are? Learning To Learn Bill Rigot1

First law of safety Never take a Sleeping pill And a Laxative At the same time In any order ….. 2

First corollary Never Remove A Safety Barrier That Has A Dent In It 3

How did this happen? 4

Bill Rigot5 Have you ever heard the head of an accident investigation board declare: “This accident was entirely predictable and preventable”

Bill Rigot6 So why can’t we predict these types of accidents?

Why Don’t We See Issues? From Karl Weik & Kathleen Sutcliffe Managing the Unexpected: “The trouble starts when I fail to notice that I see only what confirms my categories and expectations but nothing else. The trouble deepens even further if I kid myself that seeing is believing. That’s wrong. It’s the other way around. You see what you expect to see. You see what you have labels to see. You see what you have the skills to manage. Everything else is a blur. And in that ‘everything else’ lies the developing unexpected event that can bite you and undermine your best intentions.” 7

How Can You Expect the Unexpected? Very simply, you can’t You must be able to manage the unexpected As a leader, you must be able welcome bad news from your employees Variance must be viewed as a learning opportunity 8

Bill Rigot9 Why can’t we learn?

The Story of Kenny Bill Rigot10

Bill Rigot11 Complete this sentence: “Kenny is…..”

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Failure Defined… “Accidents are the unexpected combination of normal performance variability” Eric Hollnagel 13

Accidents Don’t Happen Because Workers Gamble and Lose… Accidents Happen Because: What is about to happen is simply not possible. What is about to happen has no perceived connection to what is currently happening. The possibility of getting the intended outcome is well worth whatever risk there is. 14

How We See Events Old View Human error is a cause of accidents To explain failure, investigations must seek failures of parts of systems These investigations must find inaccurate assessments and bad decisions New View Human error is a symptom of trouble deeper inside a system To explain failure, do not try to find out where people went wrong Instead, find out how peoples’ actions and assessments made sense at the time given the circumstances that surrounded them. 15

Bill Rigot16 A different way to look at failure

Start Of Job Hazard Event Normal Work Event Context: Learning Safety Understood: Drift and Accumulation Normally Successful! 17

What You Ask For Is What You Get The Pressure To Know... Outweighs The Pressure To Learn... Time Information Event NotifyLearn Fix 18

Bill Rigot19 The next time you see a variance between what should have happened and what did, ask how not why

Bill Rigot20 What does good look like in industries dedicated to learning?

Safety Redefined Safety is not the absence of accidents or events Safety is the presence of defences Bill Rigot28

Successful Organizations Seem to Do Four Things Well Constantly predicting the next failure Consistently reducing operational complication Respond with urgency to pre-cursor data Respond to serious events with deliberation Bill Rigot29

Bill Rigot30 Questions?

Additional Information Contact: Bill Rigot – – Todd Conklin Pre-Accident Investigation Podcasts: – iTunes – Bill Rigot31